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Health Assessment > Complete Health History/Documentation > Flashcards

Complete Health History/Documentation Flashcards

1
Q

Complete Health History

A

Comprehensive HX of past and present health

-Gathered on initial nonemergency visit

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2
Q

Episodic health History

A

Shorter and is specific to the patient’s current reason for seeking health care

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3
Q

Interval or Follow-up health History

A

Health history that builds on preceding visit to health care facility

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4
Q

Emergency health history

A

Health history that is ellicited from the patient and other sources in emergency situations

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5
Q

General Approach to Health History TEST

A
  1. Present w/ a professional appearance
  2. Ensure an appropriate environment
  3. Sit facing the patient at EYE LEVEL
  4. Ask the patient whether there are any questions about the interview
  5. Avoid the use of medical Jargon
  6. Reserve asking intimate and personal questions for when rapport is established.
  7. Remain Flexible
  8. Remind the pt that all info is confidential
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7
Q

Identifying Information

A

Today’s Date
-Record the month, day, year, and time that the health history is recorded.
Biographical Data
-Patient name, address, phone number, date of birth.
-Most important is the EMERGENCY CONTACT INFO

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8
Q

Source and Reliability of Information

A

In some instances, such as trauma, the historian may be someone other than the patient.

EX. Parent or Spouse

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9
Q

Patient Profile

A

Note the patient’s AGE, GENDER, RACE, & MARITAL STATUS

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10
Q

Reason for seeking Health Care

A

The reason for the patient’s visit and is usually focused on health promotion

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11
Q

Chief Complaint (CC)

A

The SIGN (objective finding) or SYMPTOM (subjective finding) that causes the patient to seek health care

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12
Q

Sign

A

Objective Finding

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13
Q

Symptom

A

Subjective finding

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14
Q

History of the Present Illness

A

Chronological account of the patient’s CC and the events surrounding it.

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15
Q

Forward Chronology

A

Origin of the symptom leading to the current status

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16
Q

10 characteristics of each Chief Complaint (CC) can be ascertained for a complete History of Present Illness (HPI)?

A
  1. Location
  2. Radiation
  3. Quality
  4. Quantity
  5. Associated manifestations
  6. Aggravating factors
  7. Alleviating factors
  8. Setting
  9. Timing
  10. Meaning and impact
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17
Q

Location of CC

A

Primary area where the symptom occurs or originates
EX.
Where does your head hurt? Can you point to the location of the pain?

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18
Q

Radiation of CC

A

Spreading of the symptom or other CC from its original location to another part of the body.
EX.
Does the headache move to another part of your head or body? If so, where?

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19
Q

Quality of CC

A

Describes the way the CC feels to the patient
-Use the Patient’s own terms to describe the quality of the CC
Ex.
Gnawing, pounding, burning, stabbing, pinching, aching, throbbing, and crushing.
What does the headache feel like?

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20
Q

Quantity of CC

A

Depicts the severity, volume, number or extent of the CC. The patient may refer to the CC with such terms as MINOR, MODERATE, or SEVERE, and SMALL, MEDIUM, OR LARGE.
EX.
Using a scale of 0 to 10, where 0 represents no pain and 10 is the worst pain that you can imagine,rate the pain that you are having now.

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21
Q

Visual Analog Scale

A

Rates pain from 0 (no pain) to 10 (worst pain possible)

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22
Q

Associated Manifestations of the CC

A

Sings and symptoms that accompany the CC

  • Positive findings
    • those associated manifestations that the patient has experienced along with the CC
  • Negative findings (Pertinent Negatives)
    • Manifestations expected in the patient w/ a suspected pathology but which are denied by the patient
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23
Q

Positive findings

A

Associated manifestations that the pt has experienced along with the CC

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24
Q

Negative Findings (Pertinent Negative)

A

Manifestations expected in the pt w/ a suspected pathology but which are denied by the pt.

25
Q

Aggravating Factors of the CC

A

Factors that worsen the severity of the CC

26
Q

Alleviating Factors

A

Events that decrease the severity of the CC

27
Q

Setting of the CC

A

Can be the actual physical environment in which the patient is located, the mental state of the patient, or some activity in which the patient was involved
EX.
What were you doing when the headache started? Where were you?

28
Q

Timing of the CC

A

The Timing used to describe a CC has 3 factors
1. onset
2. Duration
3. Frequency
EX.
When did the headache first start? How long did the headache last?

29
Q

Onset of the CC

A

refers to the time at which the CC begins and is usually described as GRADUAL or SUDDEN.

30
Q

Duration of the CC

A

Duration depicts the amount of time in which the CC is present

-Continuous and Intermittent are terms used to describe the duration of the CC.

31
Q

Frequency of the CC

A

Describes the number of times the CC occurs and how often it develops
EX.
Number of times per day, season of year.

32
Q

Meaning and Impact of the CC

A

How is the CC affecting the pt’s life??

33
Q

Past Health History (10 things)

A

Provides hearth status from birth to the Present:

  1. Medical History
  2. Surgical History
  3. Allergies
  4. Medications
  5. Communicable Diseases
  6. Injuries and Accidents
  7. Special Needs
  8. Blood transfusions
  9. Childhood illnesses
  10. Immunizations
34
Q

Medical History

A

Comprises all medical problems that the patient has experienced during adulthood and their sequelae
EX.
Have you ever been diagnosed as having an illness? what was it?

35
Q

Surgical History

A

Record a complete account of each surgical procedure, both major and minor, including the YEAR PERFORMED, HOSPITAL, PHYSICIAN, and SEQUELAE, if known,
EX
Have you ever had surgery? What type?
Who was you physician?
When, where, and by whom was the surgery performed?

36
Q

Allergies History

A

Carefully explore all patient allergies, which may include:
MEDICATIONS, ANIMALS, INSECT BITES, FOOD, & ENVIRONMENTAL ALLERGENS.
EX.
Pollen, Latex, cigarette smoke, perfume

PLACE ALLERGIES IN A CONSPICUOUS LOCATION ON THE CHART

37
Q

Medications History

A

Past and Present Consumption of Medications, both prescription and over the counter, can affect pt’s current health status.

38
Q

Prescription Medications History

A

What prescription meds are you currently taking? Who prescribed them?
What prescription meds have you TAKEN in the PAST? Who prescribed them?

39
Q

Over-The-Counter Medication History

A

Do you currently take any over-the-counter medication? Which ones?
Do you ever take aspirin, acetaminophen, ibuprofen, antacids, calcium supplements, nutritional or herbal supplements, vitamins, or laxatives?

40
Q

Communicable Diseases History

A

Ask about the patients possible exposure to communicable diseases, because pathology may not manifest itself until many years after exposure
ex
Have you ever had diptheria, tetanus, pertusis, or tb?
Have you ever had gonorrhea, syphilis, chlamydia, herpes, or other STD’s?

41
Q

Injuries and Accidents History

A

Have you every been involved in an accident?

42
Q

Special Needs History

A

The awareness of any cognitive, physical, or psychosocial disability is essential to providing individualized health care to a pt.
Ex.
Do you have any disability or special need? Describe..

43
Q

Blood Transfusions History

A

Chance of contracting an infectious disease from a blood transfusion is greatest in patients who receive a large number of transfusions, such as
-HEMOPHILIACS, ONCOLOGY PT’S & TRAUMA VICTIMS.
Ex
Have you ever received a blood transfusion?

44
Q

Childhood Illnesses

A

Ask the patient about specific childhood diseases by name.
ex.
Have you ever had any of the following illnesses: Varicella, diptheria, pertussis, measles, mumps, rubella, polio, rheumatic fever, or scarlet fever?

45
Q

Immunization history

A

What immunizations have you received since birth? When?

46
Q

Family Health History

A
  • Record health status of patient and immediate blood relatives
  • Contains:
    • Age and health status of patient and patient’s spouse, children, siblings, and parents.
  • Document info in a genogram and in a list of familial diseases
46
Q

ALWAYS ASK PT if…

A

The pt has a living will
The pt has an advanced medical directive
The pt has a durable power of attorney

Place these in the medical record and document in the assessment

47
Q

Social History

A
  • Records info about pt’s lifestyle that may affect health

- Explain why the info is important

48
Q

Tips for obtaining sensitive Info

A
  • Ask ?’s after rapport and trust established w/ the pt.
  • use direct EYE CONTACT
  • Use a matter-of-fact tone when asking ?’s
  • Adopt nonjudgemental approach
  • Use Comm technique of NORMALIZING when appropriate
49
Q

Social History (Factors)

A
  • Alcohol Use
  • Tobacco Use
  • Drug Use
  • Domestic and intimate partner violence
  • Sexual Practice
  • Travel History
  • Work History
50
Q

Domestic and Intimate partner violence (social history)

A

30% of injured women treated in ER have experienced some domestic partner violence. Is this what happened to you?

  • Use normalizing
  • does pt feel safe in current environment
51
Q

Health Maintenance activities (social History)

A

ADL = activities of daily living

-Sleep, diet, exercise, stress management, use of safety devices, health checkups

52
Q

ROS - Review of Systems

A

Pt’s subjective response to a series of body system questions
-Head to toe approach

2 Types of ?’s

  • Sign-and-symptom-related ?’s
  • Disease-related ?’s

Document Positive and pertinent negative findings

53
Q

Concluding the Health History

A
  • Ask pt whether there is additional info to discuss
  • Thank pt
  • Tell pt next step
54
Q

Documentation

A
  • Legal record of pt encounter
  • May be used by many professionals
  • Document in a professional and legally acceptable manner
  • Follow institution system
55
Q

Documentation and Guidelines

A

Ensure ACCURACY

  • ensure correct pt record or chart
  • record info immediately upon completion of encounter
  • avoid distractions
  • Date and time each entry
  • Sign each entry w/ full LEGAL NAME and PROFESSIONAL CREDENTIALS
  • Do no leave space between entries
  • Use a SINGLE LINE to CROSS OUT an error, then date, time and sign correction
  • Never correct another person’s entry
  • Use quotes to indicate direct pt response
  • Document in chronological order
  • Write legibly
  • Use permanent black ink
56
Q

Documentation Guidelines cont..

A

IF IT IS NOT DOCUMENTED, IT WAS NOT DONE

-Doc phone calls that relate to pt case

57
Q

Assessment-Specific Documentation Guidelines

A
  • Record pertinent positive and Negative assessment data
  • Document any parts of the assessment that are omitted or refused by pt
  • Avoid using judgmental language.
  • State time intervals precisely
  • Use specific measurements
  • Draw pics when appropriate
  • Refer to findings using anatomic landmarks
  • Document any change in pt’s condition during a visit or from previous visits or shift
  • Describe what you observed, not what you did.

Health Assessment (8 decks)

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